Identification of antibiotic allergies in children using prescribing patterns in the electronic medical record.

Prospective Validation of an Electronic Medical Record Report of Number of Central Line Days

Addressing the epidemic of antibiotic “allergy” over-diagnosis

Background Antimicrobial allergies and adverse reactions limit patient treatment options. “Antibiotic allergy” labeling drives broader, more toxic, and/or parenteral therapy. Published allergy data may be decades old over which time antibiotic usage has changed with newer agents introduced and greater use of several older ones. Some patient allergy designations are inaccurate; many are not true hypersensitivity. Electronic health records (EHRs) promote collection of allergy information but could inflate numbers as data are repetitively elicited and recorded. Objectives This study measured antimicrobial allergy prevalence in hospitalized adults and determined how EHR implementation affected data. Methods Retrospective chart reviews were conducted on 750+ adults seen in community teaching hospital infectious diseases consultation during each of three 6-month periods in 2007–2008, 2011–2012, and 2015–2016. Dates correspond to pre-EHR, after nursing data entry started, and after physician order entry and full electronic recordkeeping. Total antibiotic and nonantibiotic allergies were compiled and factors in recording these tracked. Results Penicillin (20.5%–22%), cephalosporin (8%–10.2%), sulfa (12%–14.1%), and fluoroquinolone (5.4%–8.9%) allergy frequencies were high. Antibiotic allergy rates were stable from 2007–2008 to 2015–2016 due to most repetitive listings being made “inactive.” However, median total drug allergies rose from 0 to 1 per patient (P < 0.01) and multiple drug intolerance (>3 unrelated drugs) increased. Conclusions Overall allergy rates for several antimicrobials were high but stable over study period; nonantibiotic allergies rose. Multidisciplinary allergy documentation is crucial in accurate data collection. Antibiotic-allergic and multiple drug intolerant patients are a good focus for prospective allergy education and “delabeling” programs.

BackgroundUp to 25% of patients admitted to hospital have an antibiotic allergy label (AAL), most of which are towards penicillin. However, up to 90% of patients who claim to be allergic to penicillin are actually able to tolerate them1. Whilst skin testing is safe and efficacious in de-labeling patients with a penicillin allergy label, it is usually not widely available. Therefore, we investigated the feasibility of de-labeling based solely upon clinical grounds. Quality of allergy documentation and subsequent antibiotic use was also assessed.MethodsThis was a cross-sectional study assessing all patients admitted to a tertiary referral teaching hospital over a 5-month period in 2016. All newly admitted patients were prospectively screened for the presence of an antibiotic allergy documented in their electronic medical record. Unless unable to participate, patients were interviewed regarding the detailed nature of their antibiotic allergy. Information regarding allergy documentation, medical condition and antibiotic use was obtained from medical records.Results3855 patients were screened, 553 (14.35%) had an AAL, and 352 were interviewed. There were 426 allergies, 276 (64.8%) towards a penicillin. Only 52% of patients had a convincing history consistent with antibiotic allergy, and 48% of these were mild cutaneous reactions. It was felt that de-labeling and direct re-challenge would be relatively safe in 70% (298/42) of AALs (if the mild cutaneous allergic group were included). In patients who were prescribed antibiotics during study admission, 25.6% (41/160) of antibiotic prescriptions in our cohort were found to be inappropriate in patients with AALs.ConclusionDirect re-challenge based upon clinical grounds appears to be a feasible clinical option in many patients with AALs and would allow de-labeling of these patients. The major barriers continue to be patient acceptance and risk of severe adverse reactions. Our study also found that major improvements could be made in the specific documentation of allergy and also in selection of guideline-recommended alternate antibiotics.1. Joint Task Force on Practice Parameters. Drug Allergy: An Updated Practice Parameter. Ann Allergy Asthma Immunol. 2010; 105(4): p. 259–273.Disclosures All authors: No reported disclosures.

It's a rash: Antibiotic allergies in the modern era of antibiotic stewardship

Many patients admitted to hospital have an antibiotic allergy (AAL) documented in their medical record. In many of these, the reaction is not a hypersensitivity reaction or may no longer be relevant. Despite this, the label adversely affects patient care directly in terms of antibiotic selection, and indirectly in terms of patient costs and the development of antimicrobial resistance. To estimate the prevalence of AALs in a cohort of hospitalised patients, to investigate the feasibility of de-labelling through re-challenge based solely upon clinical grounds. This is a cross-sectional study conducted over a 6-month period on adult inpatients. An allergy history was taken from each patient and compared with medical record data regarding allergy. Antibiotic selection data were collected (if relevant). It was then determined whether immediate de-labelling was appropriate, if direct provocation test (DPT) could be relatively safely performed, and if antibiotic selection was appropriate. Three thousand eight hundred and fifty five patients were screened, 553 (14.35%) had an AAL, and 352 were interviewed. There were 426 AALs; 276 (64.8%) towards a penicillin. After taking a detailed clinical history of the type of reaction, approximately 20% could be immediately de-labelled and educated (non-allergic, non-severe reactions) and another 38% with either a definite or vague history of mild cutaneous reaction would be suitable for an attempt at clinical de-labelling DPT. These simple measures to 'de-label' patients appropriately, would increase the quality of care of this group known to have higher costs, infection with more resistant bacteria and worse health outcomes that 'non-labelled' patients.

The purpose of the article is to compare information regarding small bowel lesions in Crohn's disease (CD) patients communicated by a published scoring system and radiology reports from electronic medical record (EMR) of cross-sectional abdominal imaging. Two gastrointestinal radiologists (reference readers) blinded to EMR reports scored cross-sectional imaging exams using a published scoring system. Investigators compared EMR and radiologist scores based on the mentioned findings and severity documentation of each variable. Statistical analysis involved means and difference in proportions and logistic regression modeling. Seventy-three CD patients, with average age 40.6years (±SD 14.4), having 80 small bowel lesions on imaging were included. EMR reports reliably mentioned within the consensus score included thickness (79%, p=0.000), enhancement (70%, p=0.000), active inflammation (86%, p=0.000), perienteric fluid (82%, p=0.000), and presence of stricture (62%, p=0.002). Minimal lumen diameter (19%, p=0.000), comb sign (19%, p=0.000), lesion length (57%, p=0.06), and fistula (50%, p=1.0) were reported less often. There was a strong association between the EMR and scoring scale in noting severity of active inflammation (88%, p=0.000), perienteric fluid (76%, p=0.000), and internal fistula (71%, p=0.000). The proportion matching severity values of comb sign and minimal lumen were 24% and 21%, respectively (p=0.000). Severity matches for stricture were less likely among the non-GI radiologists (odds ratio=0.33, SE=0.168, p=0.029). The odds of reporting stricture and fistula severity were 3.6 and 5.7, respectively, on MRE. Findings and severity of inflammation were communicated consistently. Stricture severity including minimal luminal diameter, was less reliably reported, though its prognostic significance impacts management.

It is hypothesized that 90% of antibiotic allergies documented in patients' health records are not actual, potentially life threatening, type I allergies mediated by IgE. This distinction is important because such documentation increases antibiotic resistance, as more second-choice and broad-spectrum antibiotics are then used. Evidence is lacking regarding causes of this inappropriate documentation. To develop interventions aimed at improving documentation, we explored experiences of family physicians and pharmacists in this area. We conducted a qualitative study among family physicians and pharmacists using focus group discussions, based on purposeful sampling and a naturalistic approach. Discussions were audio-recorded, transcribed verbatim, and analyzed in duplicate by means of constant comparative technique. We conducted 4 focus group discussions among 34 family physicians and 10 pharmacists, from which 3 main themes emerged: (1) magnitude and awareness of the problem of inappropriate antibiotic allergy documentation, (2) origin of the problem, and (3) approaches for addressing the problem. Participants noted that the magnitude of contamination of medical files with inappropriate documentation leads to skepticism about current documentation. Major hindering factors are electronic health record systems and electronic communication. In addition, family physicians and pharmacists believed they had insufficient knowledge about antibiotic allergies and called for tools to rectify inappropriate allergy documentation and facilitate proper documentation going forward. Family physicians and pharmacists perceive that few documented antibiotic allergies are in fact correct. Electronic health record barriers and communication barriers, as well as a lack of knowledge and facilitating tools, are main causes for numerous inappropriately documented antibiotic allergies and therefore targets for improving documentation in the future.

Approximately 2% of patients in primary care practice and up to 25% of hospital patients are registered as being allergic to an antibiotic. However, up to 90% of these registrations are incorrect, leading to unnecessary prescription of 2nd choice antibiotics with the attendant loss of efficacy, increased toxicity and antibiotic resistance. To improve registration, a better understanding is needed of how incorrect labels are attributed. To investigate the quality of antibiotic allergy registration in primary care and identify determinants to improve registration of antibiotic allergies. Registration of antibiotic allergies in primary care practices were analysed for 1) completeness and 2) correctness. To identify determinants for improvement, semi-structured interviews with healthcare providers from four healthcare domains were conducted. A total of 300 antibiotic allergy registrations were analysed for completeness and correctness. Thirty-four healthcare providers were interviewed. A registration was defined as complete when it included a description of all symptoms, time to onset of symptoms and the duration of symptoms. It was defined as correct when the conclusion was concordant with the Salden criteria. Determinants of correct antibiotic allergy registrations were divided into facilitators or obstructers. Rates of completeness and correctness of registrations were 0% and 29.3%, respectively. The main perceived barriers for correct antibiotic allergy registration were insufficient knowledge, lack of priority, limitations of registration features in electronic medical records (EMR), fear of medical liability and patients interpreting side-effects as allergies. The quality of antibiotic allergy registrations can be improved. Potential interventions include raising awareness of the consequences of incomplete and the importance of correct registrations, by continued education, and above all simplifying registration in an EMR by adequate ICT support.

Background Solid organ transplant recipients (SOTr) are at increased risk for infections post-transplantation. A penicillin allergy incidence of 12% and sulfonamide antibiotic allergy incidence of 9% has been reported in transplant recipients. Documented penicillin and sulfonamide allergies lead to the unnecessary use of broad-spectrum antibiotics or suboptimal therapy leading to further adverse consequences. The purpose of this study is to improve the rates of antibiotic allergy delabeling in SOTr prior to transplantation through the implementation of an allergy testing pilot program. Methods From December 15, 2022 to April 28, 2023, prospective SOTr with a penicillin and/or sulfonamide allergy that was tested and delabeled at OHSU were included in this study. This process involves a clinical pharmacist contacting the patient and collecting a detailed allergy history via an e-consult. The e-consult is then routed to one of our allergists to determine patient testing eligibility. If the patient qualifies for testing, they are scheduled for a nurse visit at the clinic. After testing is completed, patients are notified of their results and the allergy is removed from their electronic health record with accompanying documentation. Results A total of 86 patients were evaluated for allergy testing (61% penicillin allergies and 39% sulfonamide allergies). Fourteen patients were successfully delabeled through the pilot program with one of the patients having both a penicillin and sulfonamide allergy delabeled. The primary reason for patients being excluded from this study was due to insurance not covering allergy testing done at OHSU as shown in Table 1. Although not included in the pilot program, 7 patients were successfully delabeled by obtaining a detailed allergy history and did not require allergy testing. Twenty-two patients have a future allergy testing appointment scheduled.Table 1:Patient Inclusion and Exclusion Conclusion The preliminary results of our study show the implementation of an e-consult service for antibiotic allergy testing in prospective SOTr prior to transplantation is an effective method for allergy delabeling. Allergy testing in this patient population has the potential to significantly improve the selection of antibiotics available for treatment as well as prophylaxis. Disclosures Shyam Joshi, MD, Cogent: Honoraria|Leo Pharma: Honoraria|Nectar Allergy: Advisor/Consultant|Nectar Allergy: Stocks/Bonds|Sanofi/Regeneron: Advisor/Consultant|Sanofi/Regeneron: Honoraria|Takeda: Honoraria

Background Antibiotics are one of the leading causes of emergency room visits for adverse drug events, yet surveillance for antimicrobial allergy adverse events is limited and identifying true cases is challenging. As part of a larger study to improve antimicrobial use, we sought to develop and validate a tool for near real-time measurement of antimicrobial allergy adverse events. Methods An existing cohort of patients undergoing cardiac device procedures with known antimicrobial exposure was split into a development and validation set. Candidate triggers for identifying allergic reactionswere identified a priori, using disease phenotype codes “phecodes”, allergy documentation on allergy module of the electronic medical record (EMR), and keyword searches applied to clinical notes (e.g., “anaphylaxis,” “rash”), medication administration (e.g, corticosteroids alone or with antihistamines) and administrative codes (ICD-10 codes and phecodes). Cases were reviewed for presence of a true event, and the tool was iteratively updated based on chart review findings. The tool was then applied to the validation cohort and a sample of trigger-flagged and unflagged cases underwent manual review. Data were analyzed in SAS and model triggers were selected using a LASSO technique. Results Among 34,703 patients, N=431 cases underwent manual review (350 development; 120 validation), and 104 true allergy adverse events were identified. Among chart reviewed cases, the most frequently detected flags were keywords in unstructured clinical notes (35%), phecodes (26%), corticosteroid administration (15%), observed allergy documentation in EMR (14%) and reported allergy documentation in EMR (13%). The final model contained 7 triggers and had an AUC of 0.95, and a positive predictive value of 67% (Figure). The strongest predictors of true adverse events were the allergy health factors (aOR 358, 95% CI 76.3-999) and specific Phecodes (Table1). Conclusion We developed an antibiotic allergy measurement tool using structured and unstructured data that can be applied to detect antimicrobial adverse events in near-real time. This model may be applied to provide near real-time feedback to clinicians about antimicrobial allergy adverse events and may be useful for antimicrobial stewardship programs. Disclosures Westyn Branch-Elliman, MD, MMSc, DLA Piper,LLC/Medtronic: Advisor/Consultant|Gilead Pharmaceuticals: Grant/Research Support.

Identification of high cardiovascular risk patients on suboptimal lipid-lowering therapy (LLT) may be possible through electronic medical record (EMR) reporting, presenting an opportunity for pharmacist involvement in optimizing drug regimens. To (a) identify high cardiovascular risk patients with opportunities for LLT optimization through EMR reporting and (b) evaluate effectiveness of pharmacist review and treatment algorithm on recommending treatment modifications compared with algorithm application alone. We generated an EMR report to identify adult patients aged 21-75 years with clinical atherosclerotic cardiovascular disease and low-density lipoprotein cholesterol (LDL-C) level ≥ 70 mg/dL during a 6-month period and collected pertinent data elements. We selected a subgroup of patients for remote pharmacist review and determined recommendations based on our predefined LLT optimization algorithm and pharmacist clinical judgment. One pharmacist was responsible for making all recommendations and communicated potential treatment modification to primary care providers via email and/or EMR messaging. We tracked provider acceptable/rejection rate to all recommendations made. We also compared recommendations based on using the algorithm alone to combining pharmacist chart review and algorithm and examined reasons for any discrepancies. 941 patients met inclusion criteria, with 399 patients (42.4%) not currently on any LLT. At baseline, 249 patients (25.3%) were on a high-intensity statin, and 19 (1.9%) were on a proprotein convertase subtilisin/kexin type 9 inhibitor. A subgroup of 34 patients were reviewed, of which 30 (88.2%) were on suboptimal therapy despite not achieving LDL-C goals. The pharmacist recommended to intensify statin therapy for 16 patients (47.1%), initiate nonstatin therapy for 9 patients (26.5%), and initiate statin therapy in 5 patients (14.7%). Pharmacist recommendation acceptance rate was 53.3%, with no response received in 26.6% of cases. The algorithm evaluation alone yielded the same recommendation as the combined pharmacist review with algorithm in 30 (88.2%) of the cases and differed in 4 cases. The underutilization of LLT among high cardiovascular risk patients remains a growing issue despite effective treatment options with cardiovascular benefits. Pharmacists may be able to identify these patients by using reportable EMR data elements and applying a treatment optimization algorithm to make therapy recommendations and improve outcomes. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no relevant declarations of interest to disclose. This study was presented as a poster presentation at the APhA Annual Meeting, March 2019, Seattle, WA, and as a platform presentation at the Eastern States Conference, May 2019, Hershey, PA.

BackgroundCollaborations between medication safety and antimicrobial stewardship programs (ASP) have not been well described despite many overlapping best practice initiatives. In partnership with medication safety, the ASP at Houston Methodist (HM) reviews patient safety events submitted by hospital staff and identified a best practice opportunity in allergy reporting practices. Our objective was to benchmark self-reported antibiotic allergies among hospitalized patients and compare the prevalence and characteristics among hospital settings.MethodsWe evaluated the prevalence of self-reported antibiotic allergies in the electronic medical record for adult patients admitted to any HM entity including 1 flagship referral center (933-beds) and 6 community-based hospitals (1,379-beds) in January 2019. Antibiotics were grouped by class into penicillins, sulfas, cephalosporins, tetracyclines, macrolides, quinolones, and others. Point-prevalence rates were calculated using the total patient count as the denominator.ResultsThere were 4,730 patients admitted to HM in January 2019 of which 85% (n = 4,029) self-reported 9,186 active drug allergies. There were 2,353 (49.7%) individuals who self-reported 3,665 antibiotic allergies, of which 987 (21%) reported an allergy to ≥2 antibiotic classes. The prevalence rate for a penicillin allergy was highest at 26.1% (n = 1,235), followed by allergy to sulfa 15.9% (n = 751) and quinolones 7.9% (n = 411). Antibiotic allergies were most prevalent in patients aged 70–79 (11%, n = 518) and 60–69 (10%, n = 495). Antibiotic allergies were higher among females (61.6%; n = 1,679/2,724) compared with males (40.7%; n = 662/1,305) (P = 0.002). There was no difference in prevalence rates between community-based hospitals and the flagship institution (P = 0.51).ConclusionWe identified an antibiotic allergy point prevalence rate of 49.7% among hospitalized patients, including a 26.1% rate to penicillin, across our 7-hospital system. This analysis provides a road map to deploy system-wide efforts to improve antibiotic detailing in patients regardless of the hospital setting.DisclosuresAll authors: No reported disclosures.

BackgroundApproximately 2% of patients in primary care practice and up to 25% of hospital patients are registered as being allergic to an antibiotic. However, up to 90% of these registrations are incorrect, leading to unnecessary prescription of 2nd choice antibiotics with the attendant loss of efficacy, increased toxicity and antibiotic resistance. To improve registration, a better understanding is needed of how incorrect labels are attributed.ObjectiveTo investigate the quality of antibiotic allergy registration in primary care and identify determinants to improve registration of antibiotic allergies.DesignRegistration of antibiotic allergies in primary care practices were analysed for 1) completeness and 2) correctness. To identify determinants for improvement, semi-structured interviews with healthcare providers from four healthcare domains were conducted.ParticipantsA total of 300 antibiotic allergy registrations were analysed for completeness and correctness. Thirty-four healthcare providers were interviewed.Main measuresA registration was defined as complete when it included a description of all symptoms, time to onset of symptoms and the duration of symptoms. It was defined as correct when the conclusion was concordant with the Salden criteria. Determinants of correct antibiotic allergy registrations were divided into facilitators or obstructers.Key resultsRates of completeness and correctness of registrations were 0% and 29.3%, respectively. The main perceived barriers for correct antibiotic allergy registration were insufficient knowledge, lack of priority, limitations of registration features in electronic medical records (EMR), fear of medical liability and patients interpreting side-effects as allergies.ConclusionsThe quality of antibiotic allergy registrations can be improved. Potential interventions include raising awareness of the consequences of incomplete and the importance of correct registrations, by continued education, and above all simplifying registration in an EMR by adequate ICT support.

BackgroundRecruiting participants to clinical research studies is challenging, especially when conducted in safety net settings. We sought to compare the efficacy of different recruitment strategies in an NIH-funded study assessing treatment burden in patients with multiple chronic conditions (MCCs).MethodsTargeted mailing, in-person table-based recruitment (“tabling”) in the waiting room, and telephone calling were used to enroll subjects into one of two studies of treatment burden: a survey study to validate a brief measure of treatment burden for quality assessment (study 1) or a qualitative study to develop a treatment burden clinical communication tool (study 2).ResultsOver 50% of subjects in each study were African American or African immigrants. In study 1, the enrollment goal of 200 was reached within 4 months. Tabling enrolled 78.5% of patients, while the remainder (21.5%) were enrolled from phone calls to eligible patients identified through the electronic medical record (EMR). In study 2, 340 eligible patients were identified through the EMR, and 7 (2.1%) were successfully enrolled via mailed invitations and responses. Retention rates (66% in study 1 and 71% in study 2) were reasonable in all groups.ConclusionsStudy recruiting goals in our safety net population were rapidly reached using the tabling method, which had substantively higher enrollment rates than mailings or telephone calls based on EMR reports. Future trials could compare recruitment strategies across settings and clinical populations.